There are different approaches a physician can take with a patient in an effort to respect their autonomy, and depending upon how the practitioner understands the idea of patient autonomy. The following four models are ideals. Interactions with different patients—even the same patient at different times—may require relating within more than one type of model. The four models are Weberian ideals and highlight different visions of essential characteristics of physician/ patient interaction. Main differentiating factor is their particular conception of patient autonomy. Interactions with different patients and even the same patient at different times may require relating within more than one type of model.
| PATERNALISTIC | INFORMATIVE | INTERPRETIVE | DELIBERATIVE | |
| Goals of Interaction | That the patient receives interventions (whether the patient knows it at the time or not) that best promote their health and well-being. | Doctor to provide all relevant information for the patient to select medical interventions of their choice. | Elucidate patient’s values/ wants thereby helping patient select available medical interventions that realise those values. | Help the patient to determine/choose best health-related values that can be realised in clinical situation. |
| Doctors Obligations | Present patient with information that will encourage consent to intervention physician considers best. (Doctor is decision maker, in best interest of patient.) | Inform patient of the disease, the nature of diagnosis/treatment interventions; risks/benefits of each; uncertainties of knowledge acknowledged with patient. Doctor is technically accurate and all encompassing. | Inform patient (as previous) but also beyond this: assist patient in elucidating/ articulating values and determining what medical interventions best realise those (specific) values. | As teacher/friend, engaging the patient in dialogue on what course of action would be best. |
| Role of Patient Values | ASSUMPTION: Shared objective criteria for determining what is best (ultimately that patient will be thankful for decisions made by physician even if not agree at the time). | ASSUMPTION: clear distinction b/n facts and values — patient’s values are well defined and known (and what the patient lacks is facts). The patient’s values will determine what treatments are to be given. (NB: there is no role for the physician’s values, physician’s understanding of the patient’s values, nor the physician’s judgement of the worth of the patient’s values) | ASSUMPTION Patient’s values are not necessarily fixed and known to the patient; often patients are still in the process of developing more fully their values. The patient may only partially understand them and, they may conflict when applied to specific situations. | Knowing the patient and wishing what is best, the physician indicates what the patient should do — what decision regarding medical treatment would be advisable (having also taken into account moral imperatives that may be relevant). |
| Concept of Patient Autonomy | Patient’s agreement, either at the time or later, to the physician’s determination of what is best. | Patient controls medical decision making. | Self understanding | Moral self-development. |
| Objections to Model | Beyond limited circumstances, it is no longer tenable to assume that the physician and patient espouse similar values and views of what constitutes a benefit (in a pluralistic society with multiple and varied values) | – no place for essential qualities of ideal physician-patient relationship – i.e. lacks caring approach that requires understanding what patient values or should value, and how their illness impinges on these values (patient’s expect caring physicians not just technically proficient and detached ones) – physicians proscribed from giving a recommendation for fear of imposing their will on patient – perpetuates/ accentuates trend toward specialization and impersonalisation within medical profession – concept of patient autonomy seems philosophically untenable; assumption that persons possess known and fixed values is inaccurate; also, what of second order and changing desires? | technical specialization decreases the time available for cultivating interpretive skills – tends to paternalistic in practice – autonomy = self-understanding: excludes evaluative judgement of patient’ s values or attempts to persuade patient to adopt other values ➔ constrains guidance and recommendations that physician can offer, such as they do in preventative medicine; safe-sex counselling re: risk to others; etc. | ? Improper for doctor to judge patient’s values and promote particular health-related values because: – physicians do not possess privileged knowledge of the priority of health-related values relative to other values – nature of moral deliberation b/n physicians and patient, the physician’s recommended interventions, and the actual treatments used will depend on the values of the particular physician treating the patient – misconstrues purpose of interaction – may easily metamorphose into unintended paternalism |
Patient’s do not always want to make their own health care decisions but, at the very least, they should be made aware that they are entitled to do so. For instance, consider the following situations:
- adolescent risk-taking
- personality factors: neurotic, extraverted, open to experimentation, agreeable, conscientious
- consider theories of attitude change
- Determine fears/worries
- Assess expectations
- Inform re: diagnosis and prognosis
- Avoid medical jargon
- Spend time in conversation with patient about non-medical aspects of illness e.g. work etc.
‘4 Principle’ Approach to Ethics
- Respect for Autonomy
- Non-maleficence – summarised by ‘First do no Harm’ of Hippocratic Oath
- Beneficence
- Justice
Ethical Models: Bio-Psycho-Social model of Health and Illness
| Physiological (Disease) | Psychological (Illness) | Social (Sickness) |
| signs and symptoms; treatment is directed to cure; activity on part of the doctor and passive compliance by patient. | individual’s feelings; treatment directed to healing; activity on part of patient and facilitation by the healer. | behaviour: ‘sick role’ within patient’s culture; treat to restore normal social role; activity on part of both patient/ society or its representatives . |
